02/05/2026
Survey Tip of the Week: Significant Medication Error
Recent Ohio Department of Health (ODH) surveys have cited facilities for significant medication errors involving insulin administration, including instances where a resident received rapid-acting insulin instead of long-acting insulin resulting in hospitalization, and situations where insulin was administered despite blood glucose levels that required the medication to be held. These errors place residents at risk for serious harm and are frequently cited under F760. According to the State Operations Manual (SOM) Appendix PP, a significant medication error is one that causes resident discomfort or jeopardizes the resident’s health or safety. Determination of significance is based on the resident’s clinical condition and the circumstances of the error, including the medication involved, dose, route, timing, and the duration or frequency of the error. Surveyors consider not only whether harm occurred, but also whether there was the potential for serious harm, particularly when high-risk medications such as insulin, anticoagulants, opioids, or antipsychotics are involved.
CMS notes that medication errors may appear minor in isolation but become significant based on duration or cumulative impact. For example, omission of a laxative for one day may result in minimal discomfort; however, repeated omissions leading to constipation lasting more than three days may be considered significant if the condition progresses to fecal impaction or bowel obstruction. Surveyors evaluate whether the error contributed to unresolved symptoms, clinical decline, or increased risk to resident health and safety.
Surveyors will review whether facilities have systems in place to ensure medications are administered in accordance with physician orders, including insulin administration practices, blood glucose monitoring and parameter clarity, MAR accuracy, and communication between nursing staff and pharmacy providers. Surveyors will trace clinical decision-making related to medication administration, evaluate staff competency with high-risk medications, and assess whether medication errors are identified, investigated, and addressed through the QAPI program.
Medication errors do not need to result in permanent harm to be cited as significant. When an error creates risk, causes discomfort, or jeopardizes resident health or safety, CMS may determine the error is significant, particularly when high-risk medications are involved.
